Provider Demographics
NPI:1336785096
Name:TEESDALE, JEANNETTE MARIAN MUTCH
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:MARIAN MUTCH
Last Name:TEESDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEANNETTE
Other - Middle Name:MARIAN
Other - Last Name:MUTCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:390 RIO LINDO AVE APT 26
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-1934
Mailing Address - Country:US
Mailing Address - Phone:530-515-4132
Mailing Address - Fax:
Practice Address - Street 1:1531 ESPLANADE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3310
Practice Address - Country:US
Practice Address - Phone:530-332-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57667363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program